New Jersey Ofce of the Attorney General
Division of Consumer Affairs
State Board of Professional Engineers and Land Surveyors
124 Halsey Street, 3rd Floor, P.O. Box 45015
Newark, New Jersey 07101
(973) 504-6460
Continuing Professional Competency Approval Form
for Professional Engineers
Please complete this form if you are: 1) a program sponsor seeking Board approval pursuant to N.J.A.C. 13:40-13.5(a); or
2) an individual licensee seeking approval of a course pursuant to N.J.A.C. 13:40-13.5(b). Organizations which are exempt
pursuant to N.J.A.C. 13:40-13.5(c) do not need to submit an application.
Please print legibly.
Sponsor: ____________________________________________________________________________________________________
Address: ____________________________________________________________________________________________________
Street address City State ZIP code
Name of contact person: ___________________________________ Telephone number: _________________________________________
(include area code)
Website: _________________________________________________ E-mail address: _____________________________________
Course name: ________________________________________________________________________________________________
Course date(s): _______________________________________________________________________________________________
Total length of course/seminar in hours: _______________________
(In order to receive one CPC credit a course/seminar must be 60 minutes of class time including 50 minutes of instruction.)
Instructor’s name(s): __________________________________________________________________________________________
(Attach a copy of curriculum vitae (resume) for each instructor.)
The curriculum vitae of the lecturer, including specic background which qualies the individual as a lecturer of repute in the
area of instructions must be submitted.
Course site location: __________________________________________________________________________________________
Attach a copy of the Course Description - A detailed description of course content and estimated hours of instruction must be
submitted. (Do not send course outlines.)
Submitted by: ________________________________________________________________________________________________
Address: ____________________________________________________________________________________________________
Street address City State ZIP code
Please check one:
I am the course sponsor.
(Sponsors must submit a one-time only fee of $100.00 at the time of course submission.)
I am an individual licensee seeking approval of a course.
(Individual licensees must submit a fee of $10.00 per course.)
office use only
Approved by Committee: Yes No Date: __________________________________
Approved by: __________________________________
Course number: ________________________________ CPC credit total _________________________
Revised 4/19
